Posts Tagged ‘clinic’

“When you decline to create or to curate a culture in your spaces, you’re responsible for what spawns in the vacuum.” –Leigh Alexander

Nature abhors a vacuum. In all ways and in all places. While I have never seen this immutable law applied to group culture that only speaks to my own lack of imagination and insight, and by extension Alexander’s surfeit of both. I use “spaces” a bit differently, preferring the term as a reference to internal or personal geography (timespace, brainspace, emotionalspace). Alexander’s choice of “space” rather than “place” adds to the brilliance, the “aha”-ness of the insight in that it specifically includes the virtual as well as the physical.

Some people exert, or could exert, enormous influence over very large spaces by either actively tending to the culture or by standing aside and simply observing what fills the vacuum. The just-retired CEO of our local medical behemoth has imposed his will at a very granular level on an organization that employs 10′s of thousands. Rules and regulations abound there. The opposite was the case, at least at the outset at CrossFit, Inc. The culture arose primarily from the founder’s libertarian philosophy and worldview. Pretty freewheeling, rough and tumble, then and to some degree now.

Think for a moment about your own spaces, maybe looking initially at the ones over which you might have a bit of control or influence. Work. Home. Third space. What has your role been in the creation and ongoing curation of the culture of those spaces? It’s a rather Taoist proposition, I think: to act is precisely equal to not acting, because one or the other course must be chosen. At my day job we actually did go about the task of creating a culture (A Tribe of Adults), and we knowingly curate that space by culling the tribe of those who don’t, won’t, or can’t acculturate.

In the end this is probably just another entreaty to consciously examine your own spaces, your world, and seek to exert whatever control you can wherever you can in order to live well. Whatever “well” means to you. Again, the Tao te Ching gives us some useful vocabulary, imagery we might reference. We are all more like the pebble in the stream than the reed in the field. We may aspire to live as the reed, flexible and ever able to flow with whatever breeze may blow through. The reality is that an untended culture surrounding us flows so powerfully that it, like the water in a stream, eventually reshapes us as it inevitably sculpts the stone in the stream.

The difference, as both Lao-tse and Leigh Alexander teach us, is that you have the ability to control the flow.

I once wrote that “if you’re not living on the edge you’re taking up too much space.” This is a bit different. Effective innovators and those who are early extenders of their ideas cannot be so far outside of present orthodoxy that their innovation is ignored, however correct they may (turn out to) be. An innovation or discovery that is too radical to even be examined might be shelved simply for being too far outside the inside, thereby denying countless individuals its benefit. Incrementalism occurs in the middle, but innovation that scales happens just barely inside the border.

Think about my fitness program, CrossFit. What would likely have been the result if step one had been the spectacle of the CrossFit Games, ca. 2017? We all know the answer to that: Constantly varied functional movement at relatively high intensity (CVFMHI) would have been deemed ludicrous for all but the elite athletes we are seeing perform in the East and South Regionals this weekend, rather than a legitimate option as we seek a public health solution to the well-being of a broader population. The sentinel signal of the innovation was initially ever so slightly inside the outer boundary of the fitness/health orthodoxy: train consistently using irreducible full-body exercises at higher intensity utilizing proper movement patterns. Others have noted the importance and effectiveness of interval training, notably Michael Joyner, M.D, at the Mayo Clinic. While a sense of the importance of the glycolytic energy pathway existed before CrossFit, it took an innovator far enough outside the middle to realize its potential and make it the primary focus of a program.

The world of my day job is also populated by innovators who were just radical enough to nearly become outcasts. I always think of the great Charles Kelman, M.D., the inventor of what we now know as phacoemulsification. When Dr. Kelman began his research on using high frequency ultrasound to dissolve a cataract through an incision roughly 15-20% the size of what was then typical, no one could fathom why that would even matter. Fast forward to our present day ability to remove a cataract through a 2mm incision. Because of that first innovation I can now replace a cataract with an implant that allows someone to see both near and far with no glasses. Imagine!

Once true innovation occurs it moves inward, but a next wave of innovators lurks near the edge. Like so many benign Salieri’s to Mozart they build upon the original innovation within their own, smaller zones. This is no less disruptive than that original innovation; it simply occurs in a different part of the world. Shortly after CrossFit erupted in the general fitness world a second wave was brought by innovators in youth fitness by Jeff and Mikki Martin of Ramona California. Their program is now known as The Brand X Method and they lecture on their evolved programs for youth fitness all over the world. In a similar fashion Brian McKenzie, an ultra runner looking for a way to train more efficiently and with fewer injuries, used the principals of CrossFit as applied to endurance training in what was originally known as “CrossFit Endurance”. B Mack is also continuing to push the envelope in his PowerSpeedEndurance program.* It was only the growing acceptance of the original innovation that prevented these next-wave innovators from being OUTSIDE the edge of their particular parts of the fitness world.

The logical extension of CFVMHI, what we are witnessing each weekend as The CrossFit Games season is upon us, has long since passed me by. It turns out that for me all I’ve needed was an early update to the original inspiration (classic, early vintage CrossFit.com with CrossFit Strength Bias v3.3 layered on); more and more actually brings me less of everything. Others who I am quite fond of have had a different journey. One of my daughters-in-law is doing a modified CrossFit Endurance protocol for example, and is winning her age group in 5K races while pushing my granddaughter “The Nugget” in a race stroller. My grandson “The Man Cub” will doubtless train using the Brand X principles that have evolved from the original CrossFit Kids program. My friend Julie continues to push the limits of human everything as she competes on a CrossFit Games team while developing new medical paradigms, all before graduating from med school here in Cleveland. Unlike yours truly, more and more brings Julie more and more. Innovators in the world of eye care similarly bring us new techniques from the edges of our world, the latest being the once unthinkable ability to treat floaters with a laser.

CrossFit is now firmly established as both a system and a business. Small incision cataract surgery using ultrasound is the standard of care. We would do well to remember that time when this was not at all the case, a time when only one innovator sat just inside the outer edge. What is to come in any number of other areas–medicine, finance, digital, what have you–will come from the same place. Some of us caught on to CrossFit really early. Wouldn’t it be great to be out near the edge and catch something like that right in the beginning again?

You know you have a problem when T’ai chi hurts. Quite a come down for a guy who’s been doing CrossFit for 10+ years to be so uncomfortable that this ancient Chinese exercise causes enough discomfort that I have to sit down. Oh, it’s nothing exotic or even interesting. I have a companion sports hernia to the one that was fixed 16 years ago (note for CrossFit haters: 6 years prior to discovering CrossFit) to go with a couple of inguinal hernias. A quick little visit to Dr. Google reminds me that weakness in the pelvic floor is an inherited trait. I have a very vivid memory of my Dad joining us for a golf boondoggle wearing a monstrous, medieval apparatus called a truss to hold his hernia in while he played. Again, not CrossFit-related, but definitely messing with my CrossFit Rx for health.

It’s really weird being a patient. On the other side of the stethoscope as it were. I’m not under any illusions that my experience is a run-of-the-mill patient experience. After all, I’m a mid-career specialist who is going to have surgery at the hospital where I’ve operated for 25+ years, one that is run by my own internist and good friend. My surgeon was chosen after talking with the surgical assistants who see everyone operate. They told me who THEY would let operate on themselves and their families. My pre-op testing was arranged around my schedule in a way that was most convenient for me, the patient, and not the hospital, surgeon, or system. I picked my surgical date to coincide with a planned 4-day weekend.

Like I said, not your typical experience heading into surgery.

Nonetheless, this whole patient thing is strange. As a surgeon I am accustomed to being in control of any aspect of the surgical process I care to be involved in. Whether to do surgery and what kind of surgery to do are decisions in my hands. My herniacopia surgery? Not so much. I know that my surgeon is planning laparoscopic surgery, and that both inguinal hernias will be fixed for sure. There’s no way to know the extent of their effect on my most pressing symptoms (see what I did there?), but now that I know they are present I am hyper aware of what they are doing to me in addition to my presenting symptoms. Here’s the rub: I am convinced that it is the Spygelian or sports hernia that’s messing with me, but since it is not obvious on my pre-op CT scan my surgeon is not promising that it will be fixed. There are few things more distressing to a surgeon than not being in control of surgery, and despite all of the wonderful advantages I enjoy because of who I am, what I do, and where it’s happening, this side of the stethoscope is distressing.

What’s the big deal, then? He doesn’t see a hernia he feels is worthy of attention and only does the 2 basic, standard issue inguinal hernias. Less surgery is better than more, right? Sure. Of course it is. Unless it’s not, and that’s the big deal. I had discomfort and weakness as a 40 year old due to a Spygelian hernia on the left side. That hernia was diagnosed by a classic old-school general surgeon without any fancy imaging tests. Just an eerily well-placed index finger and a loudly yelped “YES” when he asked me “does it hurt right here?”, and off to the OR. Why he didn’t fix both sides then I’ll never know, because it was only a matter of time until the right shoe dropped.

Although CrossFit did not cause any of these problems it was definitely CrossFit that let me know I had a problem. Not only that, but it is precisely my performance, both degree and detail, that has convinced me that the Spygelian hernia is enough of an issue to fix. We measure everything in CrossFit. Time, weight, reps. We compare our results with previous efforts as a way of evaluating our fitness, and to some degree to monitor the quality of our workout programming. Gradually, over the course of 12 months or so, I have lost the ability to brace and maintain my mid-line with my abdominal muscles. In a classic cascade of calamity my secondary pelvic support muscles–gluteus medeus, piriformis, obturator, and that rat-bastard the extensor fascia lata–took over and eventually began to fail. At first it was just a little discomfort, followed by a little weakness, ending up in constant cramping and pain in all of them. At this time last year I pulled a lifetime PR in the deadlift; this weekend I could barely do reps at bodyweight.

The first place I felt pain was in that tiny little area that old-school doc poked so many years ago.

Meh. Tough spot, for me or any other patient. I’m not bringing unrefereed information from the internet to the game. I had this same thing 16 years ago, and I have objective data from my CrossFit gym that supports my contention. How best to present this to my surgeon? In this regard I am little different than anyone else with pre-op questions. At our initial visit together I laid out my symptoms and my history. During our post-CT phone call I reiterated my concern about not fixing the Spygelian hernia, however small it might be on direct visualization. Not gonna lie, the thought of having the surgery and continuing to have the same issues when I exercise makes me nauseous.

What’ll I do? Well, I guess this is the place where I really am just like everyone else when it comes to being on this side of the stethoscope. I will just have to have confidence in the surgeon I chose that he will do everything that needs to be done to solve my problem. After all, just like anyone else, I’ll be asleep while it’s going on. Kinda tough to have any input right then, ya know? It will be weeks before I will be able to really test out my results, and those weeks will likely be filled with all sorts of exotic physical therapy exercises geared toward strengthening my abs and accessory muscles, and getting my gluteus maximus to start firing again. Turns out my pain in the ass has actually been a pain in the ass…your glutes turn off in response to losing the ability to brace with your abs.

I am SO ready for this to be fixed, and I’m thinking I feel pretty good about how it’s all going to turn out. If not, well, I’m sure I’ll at least be able to enjoy pain free T’ai chi. My surgeon will undoubtedly take my concerns to heart when he is doing my surgery. After all, we will still share the same side of the stethoscope after the surgery is done.

Boy oh boy, was it crowded in the Ambulatory Surgery Center on Tuesday. The place was crawling with techie types in outfits that looked an awful lot like Walmart uniforms, bumping into a cadre of Suits who were there doing…well…I’m not sure what the Suits were doing. They were mostly in the way of productive people doing useful stuff. My day started off with an almost immediate case of miss met expectations as the tech support person who’d promised she would be there to guide me on Day One, since she’d spent so much time personally preparing both me and Epic for our first CPOE date, was nowhere to be found. Sadly, it was apparent that the otherwise quite lovely and very talented woman who was there instead, let’s call her my “Doc Minder”, was going to need some catching up on what had gone before, despite her assurances that she’d been fully prepared by Top Tech, the Doctor Whisperer.

“Dr. White, I was led to believe that all of your pre-op orders have already been entered into the system.” Uh oh. I spent 2 hours the prior Thursday afternoon with the head honcho “Doctor Whisperer” entering all of those orders. My first thought was “why don’t you know this already, since you have access to all of my charts today and could have looked?”, followed by “How is it possible that you didn’t look so that you could head off any problems before I got here?” What I said was: “they’d better be.” Ugh. Was this a sign? Given my state of mind heading into this day you can imagine the kinds of thoughts going through my head when the first mobile computer brought to the OR for my use didn’t work. Like, not at all. Rough start.

Turns out that I have some history with these mobile computers and World Class Hospital. They were originally called “Computers on Wheels”, which I instantly renamed “COWs”. Makes sense, right? Easy. Cute. Man, did that get shot down fast. Something about cultural sensitivity, or, really, I have no idea, but calling them a “COW” was verboten. I’ve been using that “Lipstick on a Pig” analogy when discussing everyone’s sensitivity to my unhappiness about Epic in general and CPOE in particular. My new four-wheeled “Pig” arrived and to my surprise things actually started to look up. The computer worked so well that I found myself calling it “Babe”.

Having all of my pre-op orders already in the system turned out to be a critical step in giving the day a fighting chance to succeed. All of the orders had, indeed, successfully made their way from the chart to the nurses in pre-op, and from there to what seemed to be a fairly regular implementation for my surgical patients. This is important because patient preparation starts well before I arrive in the morning for surgical patients, and begins for lasers while I am toiling away in the OR. The fact that it took some 2 hours to get these orders entered last week (total of 19 cases), a process that had heretofore occurred entirely without needing me to engage, was momentarily lost in the euphoria that I didn’t need to put out any pre-op order fires (hmmm…would that be a Pig roast? Sorry.).

Although this was day one for implementing CPOE in this particular ASC, the fact that the main campus of World Class Hospital, as well as several other WCH ASC’s had already made the transition, meant I really wasn’t truly a guinea pig (too much?). Standard order sets already existed for eye surgery, and it was relatively simple for the behind-the-scenes cave-dwellers to create both order sets specific for our ASC as well as templates for my op notes (more on the cave-dwellers in Part III). As I noted in Part I our turnover time in a single OR for cataract surgery is ~7:00. With some gentle and kind prompting from my “Doc Minder” I was easily able to do everything “Babe” asked of me between cases in addition to my usual duties (chat with the family, etc.). My kindly “DM” agreed that “Babe” would probably slow me down on busier days when I hop between two OR’s, but for today at least there was no time suck for cataract surgery. I even did one fewer dictation because the “Doctor Whisperer” had helped me create a template for “Complex Cataract Surgery”.

I may or may not have said “That’s some Pig!” out loud.

Alas, everyone involved knew that the happiness was fated to be short-lived. The efficiency bar is so high when we do ophthalmic lasers that there was simply no way that “Babe” was going to be able to keep up; he was back to being a Pig as soon he moseyed over to the laserium. Because every patient’s chart must be completed before they are allowed to leave the facility–images of armed guards wearing Google Glass running Epic and manning the exits filled my head–I had to attend to all of “Babe’s” needs before starting with the next patient. This process took 1.5-2X as long as usual, increasing the time it took me to do my lasers and making it a bit less convenient for my patients.

Then everything went off the rails.

Computers are computers, and software is software. They are both heroes or goats depending on how well they fulfill whatever task they are assigned, but they are prisoners of the people who operate them. The plan that all stakeholders had agreed on was for ASC staff to schedule all surgeries booked by SkyVision as of Monday by the time I finished lasers on Tuesday. I would then do all of the pre-op ordering for the following week before leaving for the day. Under the best of circumstances every minute I spend doing this is both a time and a happiness suck for me because, as I noted above, prior to CPOE I didn’t have to do ANY of it. Naturally, more than half of next week’s patients had not yet been entered into the system making it necessary to not only stick around to pet my Pig (I know) but also wait for the overworked WCH staff to complete their tasks. All in all it cost me about an hour, stealing my workout and rushing my lunch so that I could be in the office and start clinic without making my patients wait.

What’s the take-home? Tune in for Part III. For the moment let me just say…that’ll do Pig, that’ll do.

I’ve been thinking a lot about health care recently. Real health care, not Health Care as in “Health Care Crisis” or “Health Care Reform”, but the kind of health care that is provided by doctors and nurses and all kinds of other health care providers. You know, like making sick people better, and keeping healthy people healthy. The kind of health care that old guys like me (I’m 49, in case you were wondering) got from pediatricians like Dr. Roy in Southbridge, MA in the 60′s, or like my sons get from Dr. Gerace in Westlake, OH today.

I did a lot of thinking about this some 5 or so years ago, too, when I developed the concepts that eventually resulted in Skyvision Centers. My mini-epiphany at that time is that medicine is the ultimate consumer service business. At its core medicine is about one group of people providing a service to another group of people who either want or need that service. It’s the most intimate type of service, too. One to one. Face to face. You and me.

There is a remarkable lack of difference between doctors (and hospitals, for that matter) when you look at the outcomes that arise from that service– how many people get better after receiving medical care for their illnesses. The difference between the top 1 or 2% of doctors and the 50th percentile in terms of real medical outcomes is remarkably small, and much smaller today than it was in the days of my Dr. Roy.

Sure, there are differences in how people arrive at getting better. Some very instructive studies from Dartmouth have shown dramatic regional differences in the U.S. in how much money is spent on treating heart attacks, for instance. By and large, though, the same number of people get the same amount of better no matter where they are treated or from whom they received that treatment, and the quality of those treatments is several orders of magnitude greater and better than it was in my youth.

So what was it about Dr. Roy that people in my generation seem to have so much trouble finding in medical care today? If the treatment of diseases is so much better now why do so many people complain about medical care today? Why is it that Dr. Gerace has people lined up waiting to see him while other doctors don’t? Why do people rave about their experience at Skyvision Centers and complain so bitterly when they need to have a consultation at some of the most famous medical institutions in Cleveland?

I think it’s because Dr. Roy, Dr. Gerace, and I were all, once upon a time, caddies.

Seriously. We spent the earliest part of our working lives on the lowest rung of the service ladder, providing one-on-one service for a single customer. Because of that I think each of us realized that what really sets doctors (and hospitals) apart is what a patient experiences when they visit. The most successful doctors and the most successful medical practices are those who have realized that the central character in the play is the patient. The most successful caddies never forget that the most important person on the course is the golfer. The job of the caddy is to help the golfer perform a well as possible (maximize the health of her game) while at the same time making sure that she has a wonderful experience on the golf course.

Ben Stein wrote a recent column in the NY Times about his first real job; he was a shoe salesman. Imagine, at 17 years of age, selling shoes. Days filled with all manner of customers and handling the foot of each and every one of them. Customer service and sales is “learning the product you are selling, learning it so well that you can describe it while doing a pirouette of smiles for the customer and talking about the latest football scores” no matter who that customer might be. Tinker, tailor, soldier or spy, junior partner or janitor. Be they humble or haughty, gracious or grating. Totally focused on that one customer in front of you in order to provide them that service. The same can be said for any front line service job. Waitress in a diner, car mechanic, you name it.

My first summer job was caddying, and I caddied for parts of each summer through medical school. As I think about it now after reading Stein’s article it’s amazing how many parallels there are between my first job as a caddy and my career as an eye surgeon. I toted the bags for one or two golfers at a time; I usually have a patient, patient and spouse, or parent and child in the office. I was a better golfer than almost all of the men and women for whom I caddied; I know more about the eye than every patient who visits, google notwithstanding. In both circumstances my success was/is determined by my customer’s (golfer/patient) outcome, their “score”, as well as their view of the experience. Even a career-best round doesn’t feel quite as enjoyable if it took place over 6 hours in the company of a surly caddy!

I’ll tell the story of how this turned into Skyvision Centers another time; it’s a neat story and I love telling it. For the moment, though, I have a little experiment for anyone who might be listening, and a modest suggestion for the powers that be in medical education (who most assuredly AREN’T listening). The next time you visit a doctor ask him or her what their first couple of jobs were. See if you can predict which of your doctors or dentists or nurses had what kind of jobs before their medical career based on the kind of experience you’ve had in their offices or institutions.

Let’s add a little time to the education of the folks who take care of our medical problems, especially our doctors. How about 6 months selling shoes at Norstrom’s. Or a year of Sunday mornings slinging hash at a local diner. Better yet, let’s get all of those pasty white interns out on the golf course with a bag on their shoulder and a yardage book on their hip, golf hat slightly askew and Oakleys on tight (for the record, even people of color end up “washed-out” after a year of internship). Let ‘em learn how to take care of a customer without the huge advantage of all that medical knowledge. We’ll take the best of them and turn them loose in offices all across the land. Those who can’t hack it, the ones who can memorize the history of Florsheim but can’t bring themselves to touch a foot, who are scratch golfers but can’t bring themselves to congratulate the hacker who sinks a 30 foot double-breaker, those we’ll hide in the lab, or put them in huge, anonymous medical centers, one more anonymous member of an anonymous team hiding under the brand umbrella of some “World Class Clinic” where one-on-one customer service never really happens.Because the ultimate consumer service business is medicine.